MEDICARE: AMY SHAHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	113461	TX

General Provider Information

NPI Number	:	1255744561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY SHAHAN

Provider Business Mailing Address
First Line	:	305 NE LOOP 280, BUSINESS TOWER 1
Second Line	:	SUITE 200
City	:	HURST
State	:	TX
Zip	:	76053
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Provider Business Practice Location Address
First Line	:	1000 SAINT LOUIS AVE
Second Line	:	SUITE 102
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3366
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	06/04/2014

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